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What Makes a Great Root Cause System?

By Mark Paradies, President of System Improvements, Inc. TapRooT®, an EHSQ Alliance Affiliate.

WHAT MAKES A GREAT ROOT CAUSE SYSTEM?

That’s a question that I started researching back in 1985. What would I say is the answer to that question 33 years later? Here are some of my best ideas…

1. GUIDES INVESTIGATORS: The root cause system needs to guide investigators to the real, fixable root causes of human performance and equipment reliability problems. Most root cause systems don’t do this. Cause-and-effect, 5-Whys, fishbone diagrams, Why Trees, and Fault Trees all require someone on the team to know the right answer. This is especially troublesome when it comes to human error because most investigators have not been trained in human factors. Thus, they are guessing at the causes of human error.

2. NO BLAME: Blame is probably one of the biggest obstacles to finding the causes of incidents. If people think that the outcome of an investigation will be blame, you won’t get their full and free cooperation. You will start having mystery incidents where no one knows what caused the problem. That doesn’t lead to a great root cause analysis.

Some root cause systems actually have “blame categories.” (See this LINK.) Other people think that blame makes sense. But in TapRooT®, you look for causes – not blame. And if someone did something on purpose (sabotage or horseplay), you find it using the system and rule out other causes.

3.WHAT HAPPENED: You have to understand what happened BEFORE you can understand why it happened. That’s why I see many people adding a “time line” to the use of 5-Whys. If you don’t understand the sequence of events, you can’t understand the causes of what went wrong. A thorough understanding of “What happened?” is a must for great root cause analysis.

4. CONSISTENCY: If two different teams performed the root cause analysis would they find the same root causes? Many root causes systems fall short here. The analysis depends on who is on the team. And it often depends on the conclusions the investigators reach before the investigation starts. Sometimes people just set out to find their favorite causes. They are consistent … but a different team may have different favorite causes.

5. NEW IDEAS: Does your root cause system stimulate new ideas to solve problems? It should. It should provide investigators with guidance to help people fix the root causes they find.

6. A SYSTEM: You root cause analysis tool is not enough unless it is a system. A set of tools designed for a purpose. There should be a process with steps and tools to use to achieve those steps.

7. FLEXIBILITY: You should be able to use your root cause system for simple incidents or major accidents. That’s a test of the system’s flexibility. You can’t afford to train people on two systems (one for simple incidents and one for major accidents). And even if you can, you will have to get them practiced in multiple systems (which is difficult).

8. PROMOTES TRENDING: You should use the data from your root cause analysis system to understand performance and spot trends. Does your system have a built in categorization that is designed to promote accurate trending?

9. MANAGEMENT UNDERSTANDS: Your system has to be understood by your management. In fact, it should be designed so that the end result is a easy-to-understand management presentation. One that explains what happened, what caused the problems, and what we need to do to stop future incidents.

10. GREAT TRAINING: What good is a great root cause analysis system if you don’t have great training to get people to understand and use the system? You may want to inquire about the number of trainers and their experience. Can they support you around the world?

11. PROVEN EFFECTIVE: Has the system been proven to be effective by users around the world? Do they have success stories from around the globe? References that you can believe?

12. SOFTWARE SUPPORT: Does the system have effective software that makes the system even easier to use? Can that software be tied to other systems (safety or quality software)?

13. CONTINUOUSLY IMPROVED: Is the system being continuously improved? What are the plans for future improvements?

TapRooT® Root Cause Analysis is used to improve performance by analyzing and fixing problems to prevent major accidents, quality issues, equipment failures, environmental damage, and production issues. Click HERE for more information.

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